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Background: Access to affordable, quality healthcare is the key element of universal health coverage (UHC). This study examines the effectiveness of the neglected tropical disease (NTD) mass drug administration (MDA) campaign approach as a means to deliver UHC, using the example of the Liberia national programme., Methods: We first mapped the location of 3195 communities from the 2019 national MDA treatment data reporting record of Liberia. The association between coverage for onchocerciasis and lymphatic filariasis treatment achieved in these communities was then explored using a binomial geo-additive model. This model employed three key determinants for community 'remoteness': population density and the modelled travel time of communities to their supporting health facility and to their nearest major settlement., Results: Maps produced highlight a small number of clusters of low treatment coverage in Liberia. Statistical analysis suggests there is a complex relationship between treatment coverage and geographic location., Conclusions: We accept the MDA campaign approach is a valid mechanism to reach geographically marginal communities and, as such, has the potential to deliver UHC. We recognise there are specific limitations requiring further study., (© The Author(s) 2023. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene.)

Background: Lymphatic filariasis (LF) is a parasitic disease transmitted by mosquitoes, causing severe pain, disfiguring, and disabling clinical conditions such as lymphoedema and hydrocoele. LF is a global public health problem affecting 72 countries, primarily in Africa and Asia. Since 2000, the World Health Organization (WHO) has led the Global Programme to Eliminate Lymphatic Filariasis (GPELF) to support all endemic regions. This paper focuses on the achievements of the Malawi LF Elimination Programme between 2000 and 2020 to eliminate LF as a public health problem, making it the second sub-Saharan country to receive validation from the WHO., Methodology/principal Findings: The Malawi LF Programme addressed the widespread prevalence of LF infection and disease across the country, using the recommended WHO GPELF strategies and operational research initiatives in collaboration with key national and international partners. First, to stop the spread of infection (i.e., interrupt transmission) and reduce the circulating filarial antigen prevalence from as high as 74.4% to below the critical threshold of 1-2% prevalence, mass drug administration (MDA) using a two-drug regime was implemented at high coverage rates (>65%) of the total population, with supplementary interventions from other programmes (e.g., malaria vector control). The decline in prevalence was monitored and confirmed over time using several impact assessment and post-treatment surveillance tools including the standard sentinel site, spot check, and transmission assessment surveys and alternative integrated, hotspot, and easy-access group surveys. Second, to alleviate suffering of the affected populations (i.e., control morbidity) the morbidity management and disability prevention (MMDP) package of care was implemented. Specifically, clinical case estimates were obtained via house-to-house patient searching activities; health personnel and patients were trained in self-care protocols for lymphoedema and/or referrals to hospitals for hydrocoele surgery; and the readiness and quality of treatment and services were assessed with new survey tools., Conclusions: Malawi's elimination of LF will ensure that future generations are not infected and suffer from the disfiguring and disabling disease. However, it will be critical that the Malawi LF Elimination programme remains vigilant, focussing on post-elimination surveillance and MMDP implementation and integration into routine health systems to support long-term sustainability and ongoing success., Summary: Lymphatic filariasis, also known as elephantiasis, is a disabling, disfiguring, and painful disease caused by a parasite that infected mosquitoes transmit to millions of people worldwide. Since 2000, the Global Programme to Eliminate Lymphatic Filariasis (GPELF) has supported endemic countries such as Malawi in south-eastern Africa, to eliminate the disease as a public health problem. The Malawi National LF Elimination Programme has worked tirelessly over the past two decades to implement the GPELF recommended strategies to interrupt the transmission with a two-drug regime, and to alleviate suffering in patients with lymphoedema and/or hydrocoele through morbidity management and disability prevention. Additionally, the LF Programme has collaborated with national and international stakeholders to implement a range of supplementary operational research projects to address outstanding knowledge gaps and programmatic barriers. In 2020, the World Health Organisation validated that Malawi had successfully eliminated LF as a public health problem, making it the second country in sub-Saharan Africa to achieve this, which is remarkable given that Malawi previously had very high infection rates. The LF Programme now remains vigilant, putting its efforts towards post-elimination surveillance and the continued implementation of care for patients with chronic conditions. Malawi's elimination of LF will ensure that future generations are not affected by this devastating disease., Competing Interests: The authors declare that they have no competing interests., (Copyright: © 2024 Chiphwanya et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

To eliminate lymphatic filariasis (LF) by 2020, the World Health Organization (WHO) has launched a campaign against the disease. Since the launch in 2000, significant progress has been made to achieve this ambitious goal. In this article we review the progress and status of the LF programme in Africa through the WHO neglected tropical diseases preventive chemotherapy databank, the Expanded Special Project for Elimination of Neglected Tropical Diseases (ESPEN) portal and other publications. In the African Region there are 35 countries endemic for LF. The Gambia was reclassified as not requiring preventive chemotherapy in 2015, while Togo and Malawi eliminated LF as a public health problem in 2017 and 2020, respectively. Cameroon discontinued mass drug administration (MDA) and transitioned to post-MDA surveillance to validate elimination. The trajectory of coverage continues to accelerate; treatment coverage increased from 0.1% in 2000 to 62.1% in 2018. Geographical coverage has also significantly increased, from 62.7% in 2015 to 78.5% in 2018. In 2019, 23 of 31 countries requiring MDA achieved 100% geographic coverage. Although much remains to be done, morbidity management and disability prevention services have steadily increased in recent years. Vector control interventions conducted by other programmes, particularly malaria vector control, have had a profound effect in stopping transmission in some endemic countries in the region. In conclusion, significant progress has been made in the LF programme in the region while we identify the key remaining challenges in achieving an Africa free of LF., (© The Author(s) 2020. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene.)

Background: There is on-going debate about scale-up of lymphatic filariasis treatment to include urban areas. Determining Wuchereria bancrofti transmission is more complex in these settings and entomological methodologies suggested as a solution as yet have no clear guidance., Methods: The study was conducted in six communities in Minna and Kaduna cities in Nigeria selected based on pre-disposing risk factors for mosquitoes and Transmission Assessment Survey (TAS) results in 2016 indicating need for treatment (> 1% prevalence). In each community, 4 gravid traps (GT), 15 exit traps (ET) and 21 pyrethrum spray catches (PSC) were used for 5 months targeting a sample size of 10,000 mosquitoes inclusive of at least 1500 Anopheles. Community researchers were selected and trained to facilitate community acceptability and carry out collection. We have evaluated the mosquito sampling and trapping methodology in terms of success at reaching targeted sample size, cost effectiveness, and applicability., Results: Community researchers were influential in enabling high acceptability of the methods of collection and were able to conduct collections independently. Overall, 12.1% of trapping events (one trapping event corresponds to one visit to one trap to collect mosquitoes) were affected by householder actions, weather conditions or trap malfunction leading to lower than optimal catches. Exit traps were the most cost-effective way to catch Anopheles (6.4 USD per trapping event and 12.8 USD per Anopheles caught). Sample size of 10,000 mosquitoes overall in each city was met though Anopheles catch was insufficient in one city. However, sample size was met only in one implementation unit out of the four., Conclusions: Methods need adapting to maximise Anopheles catch: we propose planning 250 gravid trap and 3724 exit trap trapping events in similar settings in West African urban areas where Culex is dominant, not using pyrethrum spray catches, and weighting trapping events later in the rainy season. Planning should increase involvement of community researchers, incorporate null catches and participants' actions to predict catches. Importantly, evaluation units should be analogous with implementation units, the units at which treatment decisions will be made in the urban context.

Lymphatic filariasis (LF) and onchocerciasis are two neglected tropical diseases (NTDs) of public health significance targeted for global elimination. The World Health Organization (WHO) African Region is a priority region, with the highest collective burden of LF and onchocerciasis globally. Coendemic loiasis further complicates elimination due to the risk of adverse events associated with ivermectin treatment. A public health framework focusing on health-related data, systematic collection of data, and analysis and interpretation of data is used to highlight the range of innovative surveillance strategies required for filariasis elimination. The most recent and significant developments include: rapid point-of-care test (POCT) diagnostics; clinical assessment tools; new WHO guidelines; open-access online data portals; mHealth platforms; large-scale prevalence maps; and the optimisation of mathematical models., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

In West and Central Africa, there is a need to establish the prevalence of Wuchereria bancrofti in areas that are co-endemic for Loa loa, in order to implement the appropriate strategies to scale-up interventions for the elimination of lymphatic filariasis (LF). Due to the risk of severe adverse events (SAEs) to ivermectin in individuals with high L. loa microfilaraemia, the current strategy recommended by the World Health Organization (WHO) is twice yearly mass drug administration (MDA) with albendazole, supplemented by vector control targeting the Anopheles vectors. Defining W. bancrofti prevalence in areas co-endemic with L. loa is complicated by the cross-reactivity of rapid diagnostic immunochromatographic card tests (ICT), widely used for LF mapping, in individuals with high L. loa microfilaraemia. This has probably resulted in the overestimation of LF prevalence, triggering the implementation of MDA strategies, which may be unnecessary and wasteful of the limited resources for elimination programme implementation. Here we review the literature and present historical evidence, which uniformly highlight low or no prevalence of W. bancrofti infection and/or clinical LF cases across five Central African countries, in more than 30 different geographical areas covering 280 individual sites and > 22,000 individuals tested within high risk L. loa areas. This highlights the very limited information available on LF prevalence in L. loa areas, and potentially has major policy implications, which could shift the focus towards revised mapping criteria to verify low or no W. bancrofti prevalence in high risk L. loa areas. In this situation, revising the current WHO strategy from MDA, to focus more on ensuring high and effective vector control, through insecticide treated/long-lasting impregnated bednets (ITNs/LLINs), integration of point-of-care test-and-treat options into health systems, and consolidating closer links with the malaria control programme may be a more effective and appropriate use of the limited resources and drug donations available for LF elimination.

Lymphatic filariasis in Africa is caused by the parasite Wuchereria bancrofti and remains a major cause of morbidity and disability in 74 countries globally. A key strategy of the Global Programme for the Elimination of Lymphatic Filariasis, which has a target elimination date of 2020, is the treatment of entire endemic communities through mass drug administration of albendazole in combination with either ivermectin or diethylcarbamazine. Although the strategy of mass drug administration in combination with other interventions, such as vector control, has led to elimination of the infection and its transmission in many rural communities, urban areas in west Africa present specific challenges to achieving the 2020 targets. In this Personal View, we examine these challenges and the relevance of mass drug administration in urban areas, exploring the rationale for a reassessment of policy in these settings. The community-based mass treatment approach is best suited to rural areas, is challenging and costly in urban areas, and cannot easily achieve the 65% consistent coverage required for elimination of transmission. In our view, the implementation of mass drug administration might not be essential to interrupt transmission of lymphatic filariasis in urban areas in west Africa. Evidence shows that transmission levels are low and that effective mass drug distribution is difficult to implement, with assessments suggesting that specific control measures against filariasis in such dynamic settings is not an effective use of limited resources. Instead, we recommend that individuals who have clinical disease or who test positive for W bancrofti infection in surveillance activities should be offered antifilarial drugs through a passive surveillance approach, as well as morbidity management for their needs. We also recommend that more precise studies are done, so that mass drug administration in urban areas is considered if sustainable transmission is found to be ongoing. Otherwise, the limited resources should be directed towards other elements of the lymphatic filariasis programme., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: The Global Programme to Eliminate Lymphatic Filariasis (GPELF), launched in 2000, has the target of eliminating the disease as a public health problem by the year 2020. The strategy adopted is mass drug administration (MDA) to all eligible individuals in endemic communities and the implementation of measures to reduce the morbidity of those suffering from chronic disease. Success has been recorded in many rural endemic communities in which elimination efforts have centered. However, implementation has been challenging in several urban African cities. The large cities of West Africa, exemplified in Nigeria in Kano are challenging for LF elimination program because reaching 65% therapeutic coverage during MDA is difficult. There is therefore a need to define a strategy which could complement MDA. Thus, in Kano State, Nigeria, while LF MDA had reached 33 of the 44 Local Government Areas (LGAs) there remained eleven 'urban' LGAs which had not been covered by MDA. Given the challenges of achieving at least 65% coverage during MDA implementation over several years in order to achieve elimination, it may be challenging to eliminate LF in such settings. In order to plan the LF control activities, this study was undertaken to confirm the LF infection prevalence in the human and mosquito populations in three urban LGAs., Methods: The prevalence of circulating filarial antigen (CFA) of Wuchereria bancrofti was assessed by an immuno-chromatography test (ICT) in 981 people in three urban LGAs of Kano state, Nigeria. Mosquitoes were collected over a period of 4 months from May to August 2015 using exit traps, gravid traps and pyrethrum knock-down spray sheet collections (PSC) in different households. A proportion of mosquitoes were analyzed for W. bancrofti, using dissection, loop-mediated isothermal amplification (LAMP) assay and conventional polymerase chain reaction (PCR)., Results: The results showed that none of the 981 subjects (constituted of <21% of children 5-10 years old) tested had detectable levels of CFA in their blood. Entomological results showed that An. gambiae s.l. had W. bancrofti DNA detectable in pools in Kano; W. bancrofti DNA was detected in between 0.96% and 6.78% and to a lesser extent in Culex mosquitoes where DNA was detected at rates of between 0.19% and 0.64%. DNA analysis showed that An. coluzzii constituted 9.9% of the collected mosquitoes and the remaining 90.1% of the mosquitoes were Culex mosquitoes., Conclusion: Despite detection of W. bancrofti DNA within mosquito specimens collected in three Kano urban LGAs, we were not able to find a subject with detectable level of CFA. Together with other evidence suggesting that LF transmission in urban areas in West Africa may not be of significant importance, the Federal Ministry of Health advised that two rounds of MDA be undertaken in the urban areas of Kano. It is recommended that the prevalence of W. bancrofti infection in the human and mosquito populations be re-assessed after a couple of years.

Wuchereria bancrofti prevalence and transmission were assessed in six endemic villages in Sikasso, Mali prior to and yearly during mass drug administration (MDA) with albendazole and ivermectin from 2002 to 2007. Microfilaremia was determined by calibrated thick smear of night blood in adult volunteers and circulating filarial antigen was measured using immunochromatographic card test in children < 5 years of age. Mosquitoes were collected by human landing catch from July to December. None of the 686 subjects tested were microfilaremic 12 months after the sixth MDA round. More importantly, circulating antigen was not detected in any of the 120 children tested, as compared with 53% (103/194) before the institution of MDA. The number of infective bites/human/year decreased from 4.8 in 2002 to 0.04 in 2007, and only one mosquito containing a single infective larva was observed 12 months after the final MDA round. Whether this dramatic reduction in transmission will be sustained following cessation of MDA remains to be seen., (© The American Society of Tropical Medicine and Hygiene.)

Background: The prevalence of Wuchereria bancrofti, which causes lymphatic filariasis (LF) in The Gambia was among the highest in Africa in the 1950s. However, surveys conducted in 1975 and 1976 revealed a dramatic decline in LF endemicity in the absence of mass drug administration (MDA). The decline in prevalence was partly attributed to a significant reduction in mosquito density through the widespread use of insecticidal nets. Based on findings elsewhere that vector control alone can interrupt LF, we asked the question in 2013 whether the rapid scale up in the use of insecticidal nets in The Gambia had interrupted LF transmission., Methodology/principal Finding: We present here the results of three independently designed filariasis surveys conducted over a period of 17 years (1997-2013), and involving over 6000 subjects in 21 districts across all administrative divisions in The Gambia. An immunochromatographic (ICT) test was used to detect W. bancrofti antigen during all three surveys. In 2001, tests performed on stored samples collected between 1997 and 2000, in three divisions, failed to show positive individuals from two divisions that were previously highly endemic for LF, suggesting a decline towards extinction in some areas. Results of the second survey conducted in 2003 showed that LF was no longer endemic in 16 of 21 districts surveyed. The 2013 survey used a WHO recommended LF transmission verification tool involving 3180 6-7 year-olds attending 60 schools across the country. We demonstrated that transmission of W. bancrofti has been interrupted in all 21 districts., Conclusions: We conclude that LF transmission may have been interrupted in The Gambia through the extensive use of insecticidal nets for malaria control for decades. The growing evidence for the impact of malaria vector control activities on parasite transmission has been endorsed by WHO through a position statement in 2011 on integrated vector management to control malaria and LF.

Background: Lymphatic filariasis (LF) is a disfiguring parasitic disease and one of the leading causes of disability in the world. This study aimed to assess the severity of lymphoedema, the physical restrictions and socio-economic impact on affected individuals living in an endemic community in Malawi., Methods: In a single health centre catchment area, a follow-up survey was conducted to assess 69 lymphoedema cases, and the impact of their condition in eight different areas of their lives. Differences were examined by sex, age and severity of disease. The overall level of disability was quantified and the impact of acute dermatolymphangioadenitis (ADLA) attacks was examined., Results: Lymphoedema cases were most affected by pain/discomfort and anxiety/depression, which also had an economic impact. Male and older (>60 years) individuals reported more problems. Higher disability levels based on a quantified score were significantly associated with decreased walking distance and working hours. ADLA significantly increased pain/discomfort and reduced cognition, and also affected the individuals' self-care, social participation and ability to work., Conclusions: Filarial lymphoedema causes significant hardship, particularly in relation to ADLAs, and the scale of the problem needs to be better defined with new specific tools so that the best support and care can be provided to those in greatest need., (© The Author 2014. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

The impact of control and elimination programmes by mass drug administration (MDA) targeting onchocerciasis and lymphatic filariasis (LF) in sub-Saharan Africa over the last two decades has resulted in significantly reduced prevalence and intensity of infection, with some areas interrupting transmission. However, given that these infections are often co-endemic and the drugs (either ivermectin alone or combined with albendazole) also impact on soil transmitted helminths (STH), the importance of this, in terms of reaching the global goals has not been assessed. The additional problem posed by Loa loa, where ivermectin cannot be safely administered due to the risk of serious adverse events compounds this situation and has left populations drug naïve and an alternative strategy to eliminate LF is yet to be initiated at scale. Here, we present a series of operational research questions, which must be addressed if the effectiveness of integrated control of filarial and helminth infections is to be understood for the endgame. This is particularly important in the diverse and dynamic epidemiological landscape, which has emerged as a result of the long-term large-scale mass drug administration (or not). There is a need for a more holistic approach to address these questions. Different programmes should examine this increased complexity, given that MDA has multiple impacts, drugs are given over different periods, and programmes have different individual targets.

Lymphatic filariasis (LF) is a parasitic disease that is endemic throughout sub-Saharan Africa, infecting approximately 40 million people. In Burkina Faso, mass drug administration (MDA) for LF with ivermectin and albendazole has been ongoing since 2001, and by 2006 all endemic health districts were receiving MDA with a therapeutic coverage of at least 65%. As MDA activities scale down, the focus is now on targeting areas where LF transmission persists with alternative elimination strategies. This study explored the relationship between village-level, baseline LF prevalence data collected in 2000 with publicly available meteorological, environmental and demographic variables in order to determine the factors that influence the geographical distribution of the disease. A fitted multiple logistic regression model indicated that the length of the rainy season, variability in normalized difference vegetation index (NDVI) and population density were significantly positively associated with LF prevalence, whereas total annual rainfall, average June-September temperature, mean NDVI, elevation and the area of cotton crops were significantly negatively associated. This model was used to produce a baseline LF risk map for Burkina Faso. An extended model which incorporated potential socio-demographic risk factors also indicated a significant positive relationship between LF prevalence and wealth. In overlaying the baseline LF risk map with the number of MDA rounds, plus an insecticide-treated net (ITN) ownership measure, the central southern area of the country was highlighted as an area where baseline LF prevalence was high and ITN coverage relatively low (<50%), while at least 10 rounds of MDA had been undertaken, suggesting that more concentrated efforts will be needed to eliminate the disease in these areas.

Background: Nigeria has a significant burden of lymphatic filariasis (LF) caused by the parasite Wuchereria bancrofti. A major concern to the expansion of the LF elimination programme is the risk of serious adverse events (SAEs) associated with the use of ivermectin in areas co-endemic with Loa filariasis. To better understand this, as well as other factors that may impact on LF elimination, we used Micro-stratification Overlap Mapping (MOM) to highlight the distribution and potential impact of multiple disease interventions that geographically coincide in LF endemic areas and which will impact on LF and vice versa., Methodology/principal Findings: LF data from the literature and Federal Ministry of Health (FMoH) were collated into a database. LF prevalence distributions; predicted prevalence of loiasis; ongoing onchocerciasis community-directed treatment with ivermectin (CDTi); and long-lasting insecticidal mosquito net (LLIN) distributions for malaria were incorporated into overlay maps using geographical information system (GIS) software. LF was prevalent across most regions of the country. The mean prevalence determined by circulating filarial antigen (CFA) was 14.0% (n = 134 locations), and by microfilaria (Mf) was 8.2% (n = 162 locations). Overall, LF endemic areas geographically coincided with CDTi priority areas, however, LLIN coverage was generally low (<50%) in areas where LF prevalence was high or co-endemic with L. loa., Conclusions/significance: The extensive database and series of maps produced in this study provide an important overview for the LF Programme and will assist to maximize existing interventions, ensuring cost effective use of resources as the programme scales up. Such information is a prerequisite for the LF programme, and will allow for other factors to be included into planning, as well as monitoring and evaluation activities given the broad spectrum impact of the drugs used.

Background: The Global Programme to Eliminate Lymphatic Filariasis (GPELF) was launched in 2000, and nearly all endemic countries in the Americas, Eastern Mediterranean and Asia-Pacific regions have now initiated the WHO recommended mass drug administration (MDA) campaign to interrupt transmission of the parasite. However, nearly 50% of the LF endemic countries in Africa are yet to implement the GPELF MDA strategy, which does not include vector control. Nevertheless, the recent scale up in insecticide treated /long lasting nets (ITNs/LLINs) and indoor residual spraying (IRS) for malaria control in Africa may significantly impact LF transmission because the parasite is transmitted mainly by Anopheles mosquitoes. This study examined the magnitude, geographical extent and potential impact of vector control in the 17 African countries that are yet to or have only recently started MDA., Methods: National data on mosquito bed nets, ITNs/LLINs and IRS were obtained from published literature, national reports, surveys and datasets from public sources such as Demographic Health Surveys, Malaria Indicator Surveys, Multiple Indicator Cluster Surveys, Malaria Report, Roll Back Malaria and President's Malaria Initiative websites. The type, number and distribution of interventions were summarised and mapped at sub-national level. and compared with known or potential LF distributions, and those which may be co-endemic with Loa loa and MDA is contraindicated., Results: Analyses found that vector control activities had increased significantly since 2005, with a three-fold increase in ITN ownership and IRS coverage. However, coverage varied dramatically across the 17 countries; some regions reported >70% ITNs ownership and regular IRS activity, while others had no coverage in remote rural populations where the risk of LF was potentially high and co-endemic with high risk L.loa., Conclusions: Despite many African countries being slow to initiate MDA for LF, the continued commitment and global financial support for NTDs, and the concurrent expansion of vector control activities for malaria, is promising. It is not beyond the capacity of GPELF to reach its target of global LF elimination by 2020, but monitoring and evaluating the impact of these activities over the next decade will be critical to its success.

Background: Ivermectin and albendazole are used in annual mass drug administration (MDA) for the lymphatic filariasis elimination programmes in African countries co-endemic for onchocerciasis, but have additional impact on soil transmitted helminths and the ectoparasitic mite which causes scabies. Assessing these collateral impacts at scale is difficult due to the insensitivity of available parasite detection techniques., Methods: The numbers of cases diagnosed with intestinal helminths and scabies and who received prescriptions for treatment were evaluated in 50 health centres in Zanzibar. Records were examined from 2000, prior to the initiation of MDA to 2005, after six rounds of MDA for lymphatic filariasis had taken place., Results: Health centre records showed a consistent decline in the number of cases of intestinal helminths and scabies diagnosed by community health workers in Zanzibar and the number of prescriptions issued across five age groups. A 90-98% decline in soil transmitted helminths and 68-98% decline in scabies infections were recorded. Poisson regression models aggregated to both the island-level and district-level indicated that the decline was statistically significant., Conclusions: The described method of examining health centre records has the potential for use on a large scale, despite limitations, as a rapid method to evaluate the impacts resulting from both lymphatic filariasis and onchocerciasis MDA. This would result in a reduction in the need for parasitological evaluations to determine prevalence and intensity.

Background: The Democratic Republic of Congo (DRC) has a significant burden of lymphatic filariasis (LF) caused by the parasite Wuchereria bancrofti. A major impediment to the expansion of the LF elimination programme is the risk of serious adverse events (SAEs) associated with the use of ivermectin in areas co-endemic for onchocerciasis and loiasis. It is important to analyse these and other factors, such as soil transmitted helminths (STH) and malaria co-endemicity, which will impact on LF elimination., Results: We analysed maps of onchocerciasis community-directed treatment with ivermectin (CDTi) from the African Programme for Onchocerciasis Control (APOC); maps of predicted prevalence of Loa loa; planned STH control maps of albendazole (and mebendazole) from the Global Atlas of Helminth Infections (GAHI); and bed nets and insecticide treated nets (ITNs) distribution from Demographic and Health Surveys (DHS) as well as published historic data which were incorporated into overlay maps. We developed an approach we designate as micro-stratification overlap mapping (MOM) to identify areas that will assist the implementation of LF elimination in the DRC. The historic data on LF was found through an extensive review of the literature as no recently published information was available., Conclusions: This paper identifies an approach that takes account of the various factors that will influence not only country strategies, but suggests that country plans will require a finer resolution mapping than usual, before implementation of LF activities can be efficiently deployed. This is because 1) distribution of ivermectin through APOC projects will already have had an impact of LF intensity and prevalence 2) DRC has been up scaling bed net distribution which will impact over time on transmission of W. bancrofti and 3) recently available predictive maps of L. loa allow higher risk areas to be identified, which allow LF implementation to be initiated with reduced risk where L. loa is considered non-endemic. We believe that using the proposed MOM approach is essential for planning the expanded distribution of drugs for LF programmes in countries co-endemic for filarial infections.

Background: The Global Programme to Eliminate Lymphatic Filariasis (GPELF) was established by the World Health Organisation (WHO) in 2000 with the goal of eliminating lymphatic filariasis (LF) as a public health problem globally by 2020. Mass drug administration (MDA) of antifilarial drugs is the principal strategy recommended for global elimination. Kenya launched a National Programme for Elimination of Lymphatic Filariasis (NPELF) in Coast Region in 2002. During the same year a longitudinal research project to monitor trends of LF infection during MDA started in a highly endemic area in Malindi District. High coverage of insecticide treated nets (ITNs) in the coastal region has been associated with dramatic decline in hospital admissions due to malaria; high usage of ITNs is also expected to have an impact on LF infection, also transmitted by mosquitoes., Results: Four rounds of MDA with diethylcarbamazine citrate (DEC) and albendazole were given to 8 study villages over an 8-year period. Although annual MDA was not administered for several years the overall prevalence of microfilariae declined significantly from 20.9% in 2002 to 0.9% in 2009. Similarly, the prevalence of filarial antigenaemia declined from 34.6% in 2002 to 10.8% in 2009. All the examined children born since the start of the programme were negative for filarial antigen in 2009., Conclusions: Despite the fact that the study villages missed MDA in some of the years, significant reductions in infection prevalence and intensity were observed at each survey. More importantly, there were no rebounds in infection prevalence between treatment rounds. However, because of confounding variables such as insecticide-treated bed nets (ITNs), it is difficult to attribute the reduction to MDA alone as ITNs can lead to a significant reduction in exposure to filariasis vectors. The results indicate that national LF elimination programmes should be encouraged to continue provision of MDA albeit constraints that may lead to missing of MDA in some years.

Background: Lymphatic filariasis (LF) is a so-called neglected tropical disease, currently overshadowed by higher-profile efforts to address malaria, tuberculosis, and HIV/AIDS. Despite recent successes in arresting transmission, some 40 million people who already have the disease have been largely neglected. This study aims to increase understanding of how this vulnerable, neglected group can be helped., Methods: We used purposive sampling to select 60 men and women with filarial lymphoedema (45 with filarial elephantiasis and 15 men with filarial hydrocoele) from the south of Sri Lanka in 2004-2005. Participants were selected to give a balance of men and women and poor and nonpoor, and a range of stages of the disease. Participants' experiences and the consequences of their disease for the household were explored with in-depth qualitative, semistructured interviews., Findings: LF was extremely debilitating to participants over long periods of time. The stigma attached to the condition caused social isolation and emotional distress, and delayed diagnosis and treatment, resulting in undue advancement of the disease. Free treatment services at government clinics were avoided because the participants' condition would be identifiable in public. Loss of income due to the condition was reported by all households in the sample, not just the poorest. Households that were already on low incomes were pushed into near destitution, from which it was almost impossible to escape. Affected members of low-income households also had less opportunity to obtain appropriate treatment from distant clinics, and had living and working conditions that made hygiene and compliance difficult., Significance: This highly vulnerable category of patients has low visibility, thus becoming marginalized and forgotten. With an estimated 300,000 total cases of elephantiasis and/or oedema in Sri Lanka, and around 300,000 men with filarial hydrocoele, the affected households will need help and support for many years to come. These individuals should be specially targeted for identification, outreach, and care. The global strategy for elimination is aimed at the cessation of transmission, but there will remain some 40 million individuals with clinical manifestations whose needs and problems are illustrated in this study.

Integration of disease-specific programmes into existing health care delivery systems is a challenge for many countries, made more salient as the scope and scale of disease-specific programmes increases. This paper reports on the programmatic outcomes of 2 years of integrating the lymphatic filariasis (LF) elimination programme into primary health care (PHC) in the Dominican Republic during a period of national health care reform and decentralization. Data were collected retrospectively from community volunteers, PHC staff and LF programme staff using a mix of quantitative and qualitative methods. Benefits of integration for LF elimination included increasing the extent of the geographic coverage of mass drug administration (MDA) and a 21% increase in municipalities achieving the MDA target coverage rate of 80%. Benefits which accrued to PHC included improved information systems and strengthened relationships between the health services and the community. This study also identified challenges to implementing integration and the solutions found. These include the importance of focusing on the professional development of disease-specific program staff as their roles change, strengthening specific weakness in the general health system and finding alternative solutions where these are not easily solved, actively engaging senior management at an early stage, continually evaluating the impact of integration and not pushing integration for the sake of integration., (Copyright (c) 2007 John Wiley & Sons, Ltd.)

Programmes to eliminate lymphatic filariasis are underway in ten countries of sub-Saharan Africa, and in several programmes outside Africa five rounds of mass drug administration (MDA) are being completed. In Africa, Egypt and Zanzibar have completed five rounds of MDA. Zanzibar was the first country to complete five rounds of treatment using a combination of albendazole and ivermectin, reducing both the prevalence and intensity of Wuchereria bancrofti. Characteristics of the Zanzibar programme serve as a model for other countries: factors crucial to its success include high-level political commitment, the development of appropriate social mobilization strategies, the involvement of communities in drug distribution, and the introduction of morbidity management for individuals with lymphoedema.

Objective: To determine the relationship between human lymphatic filariasis, caused by Wuchereria bancrofti, and falciparum malaria, which are co-endemic throughout West Africa., Methods: We used geographical information systems and spatial statistics to examine the prevalence of lymphatic filariasis in relation to malaria prevalence, mosquito species distributions, vegetation and climate., Results: A negative spatial association between W. bancrofti and falciparum malaria prevalence exists. Interspecies competition between parasites, seasonality, differences in the distribution and vector competence of Anopheles vectors, agricultural practices and insecticide resistance may be factors driving current (and potentially future) spatial distributions., Conclusion: Further investigating these factors will become crucial as large-scale lymphatic filariasis and malaria control programmes are implemented in West Africa that may influence the epidemiology of both diseases.